Printable Back Pain Soap Note Template
Download
Printable Back Pain Soap Note
Prepared by: [Your Name]
I. Subjective
A. Chief Complaint
The patient reports persistent lower back pain for the past two weeks.
B. History of Present Illness (HPI)
The pain started after lifting a heavy object at work.
Described as a dull ache, occasionally sharp when bending or twisting.
Pain level: 6/10 on a numeric pain scale.
Worse with prolonged sitting or standing; improved with rest and heat application.
C. Past Medical History
History of mild sciatica 3 years ago.
No prior surgeries or major trauma.
D. Medications
Currently taking over-the-counter ibuprofen (400 mg twice daily).
E. Additional Notes
Denies numbness, tingling, or weakness in the legs.
II. Objective
A. Physical Examination Findings
Inspection: No visible deformity or swelling in the lumbar region.
Palpation: Tenderness over the L4-L5 region; no muscle spasms noted.
Range of Motion: Limited forward flexion; extension and lateral movements are mildly painful.
Neurological Exam: Normal reflexes, muscle strength, and sensation in lower extremities.
B. Diagnostic Tests
None were conducted during this visit.
III. Assessment
A. Diagnosis
Mechanical lower back pain, likely due to muscle strain.
Rule out disc herniation or other underlying conditions.
IV. Plan
A. Treatment Recommendations
Continue ibuprofen as needed for pain relief, up to 3 times daily.
Apply a heating pad for 20 minutes, 2-3 times per day.
Avoid heavy lifting and strenuous activities for the next 1-2 weeks.
B. Therapeutic Interventions
Refer to physical therapy for strengthening exercises and posture correction.
C. Follow-Up
Reassess in two weeks or sooner if symptoms worsen.
Consider imaging (X-ray or MRI) if no improvement after four weeks.
Templates
Templates
